Premorbid functional status in patients requiring veno-arterial extracorporeal membrane oxygenation after cardiac surgery.

Assessment of a patient's functional status prior to undergoing cardiac surgery may be a useful marker for predicting outcomes when postoperative veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is required. In this short communication, we present retrospective data on 83 patients at a single center who required V-A ECMO after cardiac surgery. Our results did not show a statistically significant association between premorbid functional status and mortality, though age was predictive of mortality. Future studies should explore other markers of functional status and relationships with additional outcomes.

The impact of acute kidney injury stages on the outcomes of veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: Although acute kidney injury (AKI) has been established as an independent risk factor for in-hospital mortality for patients on veno-arterial (V-A) extracorporeal membranous oxygenation (ECMO), the impact of Kidney Disease Improving Global Outcomes (KDIGO) stages of AKI has yet to be elucidated as a risk factor. METHODS: We conducted a retrospective analysis of patient outcomes based on KDIGO stages of AKI at a single institution. The analysis was a cohort of 179 patients; 66 without AKI, 19 with stage 1 AKI, 18 with stage 2 AKI, and 76 with stage 3 AKI. RESULTS: Every 1-year increase in age was associated with 4% increased odds of mortality at 30 days (95% confidence interval [CI] 1.01, 1.07; p = 0.004). The presence of AKI at any stage was associated with 59% increased odds of 30-day mortality (95% CI 0.81, 3.10; p = 0.176). The presence of stage 1 AKI was associated with a 5% decreased odds of 30-day mortality (95% CI 0.32, 2.89). The presence of stage 2 AKI (odds ratio [OR] 2.29, 95% CI 0.69, 7.55; p = 0.173) and stage 3 AKI (OR 1.68, 95% CI 0.81, 3.46; p = 0.164) was associated with increased odds of 30-day mortality. CONCLUSION: Based on our single-center study, higher KDIGO stages of AKI likely have increased odds of mortality at 30 days. Larger studies are needed to confirm these findings.

The predictive value of liver tests for the presence of liver metastases.

Aim: To analyze the predictive value of biochemical liver tests in patients with malignant melanoma, breast, colorectal or lung cancers at the time of diagnosis of liver metastases. Methods: A retrospective review of patients with the above-mentioned solid tumors at MedStar Georgetown University Hospital from 2016-2020. Results: The highest optimal cutoff according to sensitivity and specificity for the presence of liver metastases was for AST ≥1.5 × ULN for melanoma, lung, and breast cancers and ≥2 × ULN for colorectal cancer, ALT ≥1.25 × ULN for melanoma, breast and colorectal cancers and ≥1.5 × ULN for lung cancer, and ALP ≥1.5 × ULN for melanoma, breast and colorectal cancers. Conclusion: Using thresholds of liver enzymes above the ULN may improve the diagnostic accuracy for the presence of liver metastases.

Patient portal use: Persistent disparities from pre- to post-onset of the COVID-19 pandemic.

INTRODUCTION: The primary objective of this study was to examine patient portal usage from pre- to post-onset of the COVID-19 pandemic to determine what impact the pandemic had on portal usage by patient sub-populations. The second study objective was to assess differences in portal usage by chronic disorders from pre- to post-onset of the pandemic. METHODS: Patient portal data were extracted and analyzed from a non-profit healthcare system in the Mid-Atlantic region. A total of 153,628 unique patients with patient portal account were included in this study. We assessed patient portal usage from pre-onset (March 2019-February 2020) to post-onset of the COVID-19 pandemic (March 2020-February 2021). We examined usage by patient sub-populations (age, sex, race, ethnicity), comorbid conditions, and health insurance type. RESULTS: Differences were seen in specific patient portal actions. Increases were seen in immunization views (0.43, 95% CI: 0.39, 0.46) and health record views (0.43, 95% CI: 0.40, 0.46) from post-onset compared to pre-onset. A decrease was noted in prescription renewal (medication) views (-0.07, 95% CI -0.09, -0.05) from pre- to post-onset There was a decrease in both immunization views and health record views among Black patients (-0.07, 95% CI: -0.11, -0.03) in comparison to White patients, but an increase in prescription renewal (medication) views (0.07, 95%CI 0.04, 0.09) amongst Black patients compared to White patients. CONCLUSIONS: Patient portals are integral to patient care, allowing patients to actively engage in their care and communicate with their healthcare team about ongoing health needs. However, prior disparities in patient portal access have been exacerbated by the COVID-19 pandemic and solutions to address these disparities are urgently needed.

Video-Based Assessment of Microsurgical Trainees: An Evaluation of Gender Bias.

BACKGROUND: Gender bias in graduate medical evaluations remains a challenging issue. This study evaluates implicit gender bias in video-based evaluations of microsurgical technique, which has not previously been described in the literature. METHODS: Two videos were recorded of microsurgical anastomosis; the first was performed by a hand/microsurgery fellow and the second by an expert microsurgeon. A total of 150 surgeons with microsurgical experience were recruited to evaluate the videos; they were told these videos depicted a surgical trainee 1 month into fellowship followed by the same trainee 10 months later. The only variable was the name ("Rachel" or "David") that each participant was randomly assigned to evaluate. Participants were asked to score each video for quality, technique, efficiency, as well as overall progression and development after the second video compared with the initial video. To focus on bias, these outcome measures were selected to be purposefully subjective and all ratings were based on a subjective 1to 10 scale (10 = excellent). RESULTS: The analysis included 150 participants (75% male). There were no statistically significant differences in scores between the "female" and "male" trainee. The trainees received the same median initial (1-month video) and final (11th-month video) scores for all criteria except initial technique, in which the female trainee received a 7 and the male trainee received an 8. Notably, 11-month scores were consistently the same or lower than 1-month scores for both study groups (p < 0.001). There were also no differences within either study group based on participant sex. Microsurgery practitioners overall rated both groups lower than those who do not currently practice microsurgery. CONCLUSION: Our study did not identify a gender bias in this evaluation method. Further investigation into how we assess and grade trainees as well as the presence and impact of implicit biases on varying surgical assessment methods is warranted.

Prevalence and clinical risk factors for esophageal candidiasis in non-human immunodeficiency virus patients: A multicenter retrospective case-control study.

BACKGROUND: Although esophageal candidiasis (EC) may manifest in immunocompetent individuals, there is a lack of consensus in the current literature about predisposing conditions that increase the risk of infection. AIM: To determine the prevalence of EC in patients without human immunodeficiency virus (HIV) and identify risk factors for infection. METHODS: We retrospectively reviewed inpatient and outpatient encounters from 5 regional hospitals within the United States (US) from 2015 to 2020. International Classification of Diseases, Ninth and Tenth Revisions were used to identify patients with endoscopic biopsies of the esophagus and EC. Patients with HIV were excluded. Adults with EC were compared to age, gender, and encounter-matched controls without EC. Patient demographics, symptoms, diagnoses, medications, and laboratory data were obtained from chart extraction. Differences in medians for continuous variables were compared using the Kruskal-Wallis test and categorical variables using chi-square analyses. Multivariable logistic regression was used to identify independent risk factors for EC, after adjusting for potential confounding factors. RESULTS: Of the 1969 patients who had endoscopic biopsies of the esophagus performed from 2015 to 2020, 295 patients had the diagnosis of EC. 177 of 1969 patients (8.99%) had pathology confirming the diagnosis of EC and were included in the study for data collection and further analysis. In comparison to controls, patients with EC had significantly higher rates of gastroesophageal reflux disease (40.10% vs 27.50%; P = 0.006), prior organ transplant (10.70% vs 2%; P < 0.001), immunosuppressive medication (18.10% vs 8.10%; P = 0.002), proton pump inhibitor (48% vs 30%; P < 0.001), corticosteroid (35% vs 17%; P < 0.001), Tylenol (25.40% vs 16.20%; P = 0.019), and aspirin use (39% vs 27.50%; P = 0.013). On multivariable logistic regression analysis, patients with a prior organ transplant had increased odds of EC (OR = 5.81; P = 0.009), as did patients taking a proton pump inhibitor (OR = 1.66; P = 0.03) or corticosteroids (OR = 2.05; P = 0.007). Patients with gastroesophageal reflux disease or medication use, including immunosuppressive medications, Tylenol, and aspirin, did not have a significantly increased odds of EC. CONCLUSION: Prevalence of EC in non-HIV patients was approximately 9% in the US from 2015-2020. Prior organ transplant, proton pump inhibitors, and corticosteroids were identified as independent risk factors for EC.

Bridging the Digital Health Divide: Characterizing Patient Portal Users and Nonusers in the U.S.

OBJECTIVE: The objectives of this study were to (1) examine demographic differences between patient portal users and nonusers; and (2) examine health literacy, patient self-efficacy, and technology usage and attitudes between patient portal users and nonusers. METHODS: Data were collected from Amazon Mechanical Turk (MTurk) workers from December 2021 to January 2022. MTurk workers completed an online survey, which asked about their health, access to technology, health literacy, patient self-efficacy, media and technology attitudes, and patient portal use for those with an account. A total of 489 MTurk workers completed the survey. Data were analyzed using latent class analysis (LCA) and multivariate logistic regression models. RESULTS: Latent class analysis models revealed some qualitative differences between users and nonusers of patient portals in relation to neighborhood type, education, income, disability status, comorbidity of any type, insurance type, and the presence or absence of primary care providers. These results were partially confirmed by logistic regression models, which showed that participants with insurance, a primary care provider, or a disability or comorbid condition were more likely to have a patient portal account. CONCLUSIONS: Our study findings suggest that access to health care, along with ongoing patient health needs, influence the usage of patient portal platforms. Patients with health insurance have the opportunity to access health care services, including establishing a relationship with a primary care provider. This relationship can be critical to a patient ever creating a patient portal account and actively engaging in their care, including communicating with their care team.

Pulmonary Artery Dual-Lumen Cannulation Versus Two Cannula Percutaneous Extracorporeal Membrane Oxygenation Configuration in Right Ventricular Failure.

Refractory right ventricular failure has significant morbidity and mortality. Extracorporeal membrane oxygenation is indicated when medical interventions are deemed ineffective. However, it is still being determined if one configuration is better. We conducted a retrospective analysis of our institutional experience comparing the peripheral veno-pulmonary artery (V-PA) configuration versus the dual-lumen cannula with the tip in the pulmonary artery (C-PA). The analysis of a cohort of 24 patients (12 patients in each group). There was no difference in survival after hospital discharge (58.3% in the C-PA group compared to 41.7% in the V-PA group, p = 0.4). Among the C-PA group, there was a statistically significant shorter ICU length of stay (23.5 days [interquartile range {IQR} = 19-38.5] vs. 43 days [IQR = 30-50], p = 0.043) and duration of mechanical ventilation (7.5 days [IQR = 4.5-9.5] compared to (16.5 days [IQR = 9.5-22.5], p = 0.006) in the V-PA group. In the C-PA group, there were lower incidents of bleeding (33.33% vs. 83.33%, p =0.036) and combined ischemic events (0 vs. 41.67%, p = 0.037). In our single-center experience, the C-PA configuration might have a better outcome than the V-PA one. Further studies are needed to confirm our findings.

HCV universal EHR prompt successfully increases screening, highlights potential disparities.

BACKGROUND & OBJECTIVES: Screening for hepatitis C virus is the first critical decision point for preventing morbidity and mortality from HCV cirrhosis and hepatocellular carcinoma and will ultimately contribute to global elimination of a curable disease. This study aims to portray the changes over time in HCV screening rates and the screened population characteristics following the 2020 implementation of an electronic health record (EHR) alert for universal screening in the outpatient setting in a large healthcare system in the US mid-Atlantic region. METHODS: Data was abstracted from the EHR on all outpatients from 1/1/2017 through 10/31/2021, including individual demographics and their HCV antibody (Ab) screening dates. For a limited period centered on the implementation of the HCV alert, mixed effects multivariable regression analyses were performed to compare the timeline and characteristics of those screened and un-screened. The final models included socio-demographic covariates of interest, time period (pre/post) and an interaction term between time period and sex. We also examined a model with time as a monthly variable to look at the potential impact of COVID-19 on screening for HCV. RESULTS: Absolute number of screens and screening rate increased by 103% and 62%, respectively, after adopting the universal EHR alert. Patients with Medicaid were more likely to be screened than private insurance (ORadj 1.10, 95% CI: 1.05, 1.15), while those with Medicare were less likely (ORadj 0.62, 95% CI: 0.62, 0.65); and Black (ORadj 1.59, 95% CI: 1.53, 1.64) race more than White. CONCLUSIONS: Implementation of universal EHR alerts could prove to be a critical next step in HCV elimination. Those with Medicare and Medicaid insurance were not screened proportionately to the national prevalence of HCV in these populations. Our findings support increased screening and re-testing efforts for those at high risk of HCV.

Use of Treatments after Recovery from Thumb Carpometacarpal Arthritis Surgery.

BACKGROUND: Which treatments patients continue to use more than 1 year after primary thumb carpometacarpal arthritis surgery, and how such use relates to patient-reported outcomes, is largely unknown. METHODS: The authors identified patients who had isolated primary trapeziectomy alone or with ligament reconstruction ± tendon interposition and were 1 to 4 years postoperative. Participants completed a surgical site-focused electronic questionnaire about what treatments they still used. Patient-reported outcome measures were the Quick Disability of the Arm, Shoulder, and Hand questionnaire and visual analog/numerical rating scales for current pain, pain with activities, and typical worst pain. RESULTS: A total of 112 patients met inclusion and exclusion criteria and participated. At a median of 3 years after surgery, over 40% reported current use of at least one treatment for their thumb carpometacarpal surgical site, with 22% using more than one treatment. Of those who still used treatments, 48% used over-the-counter medications, 34% used home or office-based hand therapy, 29% used splinting, 25% used prescription medications, and 4% used corticosteroid injections. A total of 108 participants completed all patient-reported outcome measures. With bivariate analyses, the authors found that use of any treatment after recovering from surgery was associated with statistically and clinically significantly worse scores for all measures. CONCLUSIONS: Clinically relevant proportions of patients continue to use various treatments a median of 3 years after primary thumb carpometacarpal arthritis surgery. Continued use of any treatment is associated with significantly worse patient-reported outcomes for function and pain.

Evaluating Language Characteristics and Related Gender Bias in Letters of Recommendation for Hand Surgery Fellowship.

PURPOSE: Letters of recommendation (LORs) function as an indicator of competence and future potential for a trainee. Our purpose was to evaluate gender bias in hand surgery fellowship applicant LORs. METHODS: This was a retrospective study of all LORs submitted to a hand surgery fellowship program between 2015 and 2020. Demographic data about applicants and letter writers were collected. Linguistic analysis was performed using a text analysis software, and results were evaluated with nonparametric tests, multiple linear regression models, and a mixed effects regression model. RESULTS: Letters of recommendation were analyzed; 720 letters for 188 (23.4%) female applicants and 2,337 letters for 616 (76.6%) male applicants. Compared with LORs written for men, those written for women had more references to categories of anxiety (eg, worried and fearful) and affiliation (eg, ally and friend). Letters for women had more "clout." In subgroup analysis, letters for female plastic surgery applicants had more words signaling power, whereas recommendations for female applicants from orthopedic residencies had more words related to anxiety, achievement, work, and leisure. CONCLUSIONS: Letters of recommendation written for female residents applying to hand fellowship had more references to anxiety but were written with higher clout and more words of affiliation. Subgroup analysis looking at orthopedic and plastic surgery applicants separately found a mixed picture. Overall, these LORs written for applicants to hand fellowship had no notable specific patterns of gender bias in our analyses. CLINICAL RELEVANCE: Because programs look to train the next generation of hand surgeons, alerting letter readers to trends in implicit bias may help in the selection of qualified applicants. Bringing topics of implicit bias forward may help writers think more critically about word choice and topics.

Patient-Reported Data Augment Prediction Models of Persistent Opioid Use after Elective Upper Extremity Surgery.

BACKGROUND: Opioids play a role in pain management after surgery, but prolonged use contributes to developing opioid use disorder. Identifying patients at risk of prolonged use is critical for deploying interventions that reduce or avoid opioids; however, available predictive models do not incorporate patient-reported data (PRD), and it remains unclear whether PRD can predict postoperative use behavior. The authors used a machine learning approach leveraging preoperative PRD and electronic health record data to predict persistent opioid use after upper extremity surgery. METHODS: Included patients underwent upper extremity surgery, completed preoperative PRD questionnaires, and were prescribed opioids after surgery. The authors trained models using a 2018 cohort and tested in a 2019 cohort. Opioid use was determined by patient report and filled prescriptions up to 6 months after surgery. The authors assessed model performance using area under the receiver operating characteristic, sensitivity, specificity, and Brier score. RESULTS: Among 1656 patients, 19% still used opioids at 6 weeks, 11% at 3 months, and 9% at 6 months. The XGBoost model trained on PRD plus electronic health record data achieved area under the receiver operating characteristic 0.73 at 6 months. Factors predictive of prolonged opioid use included income; education; tobacco, drug, or alcohol abuse; cancer; depression; and race. Protective factors included preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health and Upper Extremity scores. CONCLUSIONS: This opioid use prediction model using preintervention data had good discriminative performance. PRD variables augmented electronic health record-based machine learning algorithms in predicting postsurgical use behaviors and were some of the strongest predictors. PRD should be used in future efforts to guide proper opioid stewardship. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Prescription Opioids and Patient-Reported Outcomes and Satisfaction After Carpal Tunnel Release Surgery.

BACKGROUND: Amount of opioid use correlates poorly with procedure-related pain; however, prescription limits raise concerns about inadequate pain control and impacts on patient-reported quality indicators. There remain no consistent guidelines for postoperative pain management after carpal tunnel release (CTR). We sought to understand how postoperative opioid use impacts patient-reported outcomes after CTR. METHODS: This is a pragmatic cohort study using prospectively collected data from all adult patients undergoing uncomplicated primary CTR over 17 months at our center. Patients were categorized as having received or not received a postoperative opioid prescription, and then as remaining on a prescription opioid at 2-week follow-up or not. Questionnaires were completed before surgery and at 2-week follow-up. We collected brief Michigan Hand questionnaire (bMHQ) score, Patient-Reported Outcomes Measurement Information System Global Health score, satisfaction, and pain score. RESULTS: Of 505 included patients, 405 received a postoperative prescription and 67 continued use at 2-weeks. These 67 patients reported lower bMHQ, lower satisfaction, and higher postoperative pain compared to those that discontinued. Multivariable regressions showed that receiving postoperative prescriptions did not significantly influence outcomes or satisfaction. However, remaining on the prescription at 2 weeks was associated with significantly lower bMHQ scores, particularly in patients reporting less pain. CONCLUSIONS: Patients remaining on a prescription after CTR reported worse outcomes compared to those who discontinued. Unexpectedly, the widest bMHQ score gap was seen across patients reporting lowest pain scores. Further research into this high-risk subgroup is needed to guide policy around using pain and patient-reported outcomes as quality measures.Level of Evidence: Level III.

Billing and Utilization Trends for Hand Surgery Indicate Worsening Barriers to Accessing Care.

BACKGROUND: Hospitals and providers may increase hand surgery charges to compensate for decreasing reimbursement. Higher charges, combined with increasing utilization of ambulatory surgical centers (ASCs), may threaten the accessibility of affordable hand surgery care for uninsured and underinsured patients. METHODS: We queried the Physician/Supplier Procedure Summary to collect the number of procedures, charges, and reimbursements of hand procedures from 2010 to 2019. We adjusted procedural volume by Medicare enrollment and monetary values to the 2019 US dollar. We calculated weighted means of charges and reimbursement that were then used to calculate reimbursement-to-charge ratios (RCRs). We calculated overall change and r2 from 2010 to 2019 for all procedures and stratified by procedural type, service setting, and state where service was rendered. RESULTS: Weighted mean charges, reimbursement, and RCRs changed by + 21.0% (from $1,227 to $1,485; r2 = 0.93), +10.8% (from $321 to $356; r2 = 0.69), and -8.4% (from 0.26 to 0.24; r2 = 0.76), respectively. The Medicare enrollment-adjusted number of procedures performed in ASCs increased by 63.8% (r2 = 0.95). Trends in utilization and billing varied widely across different procedural types, service settings, and states. CONCLUSIONS: Charges for hand surgery procedures steadily increased, possibly reflecting an attempt to make up for reimbursements perceived to be inadequate. This trend places uninsured and underinsured patients at greater risk for financial catastrophe, as they are often responsible for full or partial charges. In addition, procedures shifted from inpatient to ASC setting. This may further limit access to affordable hand care for uninsured and underinsured patients.

Comparison of 3 Dynamic External Fixation Devices for Proximal Interphalangeal Joint Dorsal Fracture-Dislocations in a Cadaver Model.

PURPOSE: Several improvised dynamic external fixation devices are used for treating unstable dorsal proximal interphalangeal (PIP) joint fracture-dislocations. We compared the effectiveness of 3 constructs for simulated dorsal PIP joint fracture-dislocations in a cadaver model. METHODS: We tested 30 digits from 10 fresh-frozen, thawed cadaver hands. We aimed to remove the palmar 50% of the base of each digit's middle phalanx (P2), simulating an unstable dorsal PIP joint fracture-dislocation. Each PIP joint was then stabilized via external fixation with either a pins-and-rubber-bands construct, pins-only construct, or tuberculin syringe-pins construct. We allocated 10 digits per fixation group. The finger tendons were secured to a computer-controlled stepper motor-driven linear actuator. Via this mechanism, all PIP joints were taken through 1,400 cycles of flexion-extension. With the PIP joint in neutral extension, we measured the P2 dorsal translation at baseline, after fixator stabilization, and after the motion protocol. RESULTS: The actual mean P2 palmar defect created was 48% of the base. All PIP joints were unstable after creating the defect, with a mean initial P2 dorsal displacement of 3.7 mm. After application of the fixators, all PIP joint dislocations were reduced. The median residual P2 dorsal displacements were 0.0 mm for the pins-rubber bands group, 0.1 mm for the pins-only group, and 0.5 mm for the syringe-pins group. There were no cases of PIP joint redislocation after flexion-extension cycling, and the median dorsal P2 displacements were 0.0 mm for the pins-rubber bands group; 0.0 mm for the pins-only group; and 0.5 mm for the syringe-pins group. CONCLUSIONS: All 3 external fixators restored PIP joint stability following simulated dorsal fracture-dislocation, with all reductions maintained after motion testing. The syringe-pins construct had significantly greater median residual P2 dorsal displacement after the initial reduction and motion testing, which is of unclear clinical importance. CLINICAL RELEVANCE: This study informs surgeon decision-making when considering dynamic external fixator options for dorsal PIP joint fracture-dislocations.

Passive Manipulation for Proximal Interphalangeal Joint Extension Contractures.

PURPOSE: We investigated closed passive manipulation as an alternative to surgery for certain proximal interphalangeal (PIP) joint extension contractures. METHODS: We retrospectively reviewed all patients with PIP joint extension contractures treated with passive manipulation at our institution between 2015 and 2019. The included patients were a minimum of 12 weeks from their initial injury/surgery (median 179 days; interquartile range: 130-228 days), had plateaued with therapy, and underwent a 1-time passive manipulation. All included fingers had congruent PIP joints and no indwelling hardware that could have had direct adhesions. Most (80%) patients had a direct injury to the finger ray(s) that led to the contractures. Most (75%) patients had the manipulation performed under local anesthesia in the office. Available measures of passive range of motion (PROM) and active range of motion (AROM) immediately, within 6 weeks, between 6 and 12 weeks, and at >12 weeks after the manipulation were recorded. RESULTS: Twenty-eight patients and 46 digits met the criteria. The median PIP joint PROM improved from 50° to 90° immediately following the manipulation. The median PROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks following manipulation were 80°, 85°, and 85°, respectively. The median AROM immediately after the manipulation improved from 40° to 90°, and the median AROM values within 6 weeks, between 6 and 12 weeks, and at >12 weeks were 70°, 50°, and 60°, respectively. None of the patients experienced worsening of PIP joint range of motion. One patient who had 4 fingers manipulated had a 45° distal interphalangeal joint extension lag for one of the fingers after the manipulation. Eight fingers underwent later flexor tenolysis or reconstruction to improve AROM after the gains in PROM via manipulation were maintained. CONCLUSIONS: Passive manipulation is an alternative to surgical release for select PIP joint extension contractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

All-Suture Anchor Repair of the Flexor Digitorum Profundus Insertion: A Biomechanical Comparison of 2 Suturing Techniques.

PURPOSE: We compared 2 suturing techniques for reattachment of the flexor digitorum profundus (FDP) via all-suture anchor. METHODS: We used fresh, matched-pair, cadaveric hands. We disarticulated the fingers at the proximal interphalangeal joints, preserving the proximal FDP. We released the FDPs at their distal insertion and placed an all-suture, 1.0-mm anchor at the center of each FDP footprint. Each anchor's sutures were used to reattach each FDP using 1 of 2 techniques: group H (n = 14) via horizontal mattress; group H + K (n = 12) via horizontal mattress with knots thrown and, with each suture tail, 3 proximal, running-locking, Krackow-type passes on the radial and ulnar FDP sides with the suture ends tied together. We excluded 2 specimens from the H + K group because of improper anchor placement. All other fingers in both groups were individually mounted in an MTS machine for FDP loading in the following sequence for 500 cycles each: (1) to 15 N to simulate passive motion forces; (2) to 19 N for short-arc active motion forces; and (3) to 28 N for full active motion forces. Specimens that had not failed during cyclic testing were then loaded to failure. We measured FDP-to-bone gapping via a digital transducer. We defined failure as >3-mm gapping. RESULTS: The H + K group had significantly less gapping during cyclic loading up to 19 N and significantly higher load to failure. The H + K group failed exclusively at the anchor-bone level; the H group failed mostly by suture-tendon pullout. CONCLUSIONS: The H + K group performed significantly better regarding cyclic and load-to-failure testing after FDP reattachment. CLINICAL RELEVANCE: The H + K technique combines the benefits of horizontal-mattress tendon-to-bone apposition and Krackow-tendon locking. It converts the point of failure to the bone level rather than the suture-tendon level.

Pain Control and Satisfaction With Peripheral Nerve Blocks for Upper Extremity Surgery.

BACKGROUND: Regional anesthesia ("block") is an important component of upper extremity (UE) surgery pain control. However, little is known about patient experience related to perioperative opioid use. This study assessed patient-reported pain control and satisfaction with UE blocks and evaluated how opioid consumption impacted these outcomes before the block "wore off." METHODS: A postoperative phone survey was administered to patients who underwent outpatient UE surgery at a surgery center for more than 16 months. It assessed pain scores (scale 1-10), satisfaction with block duration (scale 1-5), duration until return of UE function, and opioid consumption. Analyses used Mann-Whitney U tests, Fisher exact tests, and bivariate and multivariable linear and ordered logistic regressions to understand relationships between opioid use and outcomes. RESULTS: A total of 509 patients (61%) completed the survey, and 441 (88%) were satisfied with block duration. Initial and final pain scores were significantly higher in patients who took opioids prior to the block wearing off (6 and 4.5, P = .04 and 3.5 and 2, P = .002, respectively). Although satisfaction with block duration was not different in group comparisons (ie, patients who premedicated vs those who did not), in a multivariable analysis, patients who premedicated with opioids had 78% increased odds of reporting the highest level of satisfaction compared with the lower 4 levels (P = .03). CONCLUSIONS: Upper extremity blocks are associated with high overall patient satisfaction and postsurgical pain control. Premedicating before the block wears off may increase patient satisfaction with block duration even if pain is not notably impacted.

Describing Adverse Events Associated with Bilateral Same-Day Intravitreal Dexamethasone Implants.

BACKGROUND AND OBJECTIVES: To explore the incidence of adverse events after bilateral same-day intravitreal 0.7-mg dexamethasone implant (SDIDI) injections. MATERIALS AND METHODS: We performed an IRB approved, single-center, retrospective review of patients receiving bilateral SDIDI injections from January 1, 2016 to October 31, 2021 and reviewed adverse events that occurred within 3 months of injection. RESULTS: A total of 206 bilateral (412 eyes) SDIDI injections were performed in 59 patients. Ocular hypertension or the addition of intraocular pressure (IOP) lowering drops occurred in 121 (29.4%) eyes after IDI. Two (0.5%) eyes required glaucoma drainage surgeries. Of the 117 phakic eyes, 32 (27.4%) had progression of cataract or cataract extraction. There were two (0.5%) episodes of vitreous hemorrhage and one (0.2%) retinal tear with retinal detachment. There were no cases of endophthalmitis. CONCLUSION: Serious complication rates after bilateral same-day IDI injections appears low. Increased IOP that requires intervention can occur. [Ophthalmic Surg Lasers Imaging Retina 2022;53:612-618.].